New Client/Patient Survey Milan Area Animal Hospital (MAAH) is currently booking 3 - 4 weeks out for appointments and we are no longer accepting new clients on an emergent basis. Here at MAAH we want to partner with you for your pet(s) healthcare needs. Due to a massive increase in client needs recently, we are no longer able to accept new clients without pre-screening to ensure that we are establishing a good doctor/client relationship. A good veterinary doctor/client relationship is based on honesty, respect and communication. Please fill this form out and return with all previous veterinary history. CLIENT INFORMATION: Name* First Last Phone** CELL HOME Alt Phone:Alternate Contact Name:Relationship:Phone:Is pet residing with Primary client?* Yes No If yes, for how long?Permission for alternate to give consent for procedures and/or medications?* Yes No PATIENT INFORMATION: Pet Name*NicknameSpecies:* Canine Feline Avian Rodent Reptile BreedAge*Sex*Spayed/Neutered* Yes No At what age was pet spayed/neutered?*What is your pets normal diet?Is this pet kept current on: Vaccinations (Distemper, Rabies, etc.)* Yes No If not current, when was the last time given?Yearly Blood work (Chemistries & CBC)* Yes No If not current, when was the last time done?Heartworm Testing* Yes No If not current, when was the last time done?Testing for Tick-Borne Diseases (inc Lyme) Yes No If not current, when was the last time done?Fecal tests* Yes No How often is testing done? Every 6 Months Yearly If not current, when was the last time done?Is your pet on heart-worm prevention?* Yes No If yes, which oneDo you keep your pet on this prevention year round? Yes No Is your pet on flea & tick prevention?* Yes No If yes, which oneDo you keep your pet on this prevention year round Yes No Is your pet on any other medications? (Please list medication, frequency, and condition being treated) Does your pet have a Chronic medical condition? Yes No If yes, describe belowDoes your pet reside* Inside Outdoors Both Does your pet have any behavioral problems that you are concerned with?* Yes No If yes, explain I hereby agree that the information provided is true and precise, to the best of my knowledge. Signature*Date* MM slash DD slash YYYY Medical Records Drop files here or Select files Max. file size: 2 GB. Did you have your records sent to our office at 734-439-0556? If not, please upload records at this time.
